India- Free medicine scheme gets Rs 1,300 crore boost #rightohealth


Kounteya SinhaKounteya Sinha, TNN | Sep 20, 2012, 02.12AM IST

Union health minister Ghulam Nabi Azad has cleared Rs 1,300 crore under the National Rural Health Mission (NRHM) for states to support their purchase of medicines.
NEW DELHI: India has made its first major move towards providing free medicines for all.

Union health minister Ghulam Nabi Azad has cleared Rs 1,300 crore under the National Rural Health Mission (NRHM) for states to support their purchase of medicines. The largesse will not only help buy general drugs for government-run hospitals but also those needed under the Janani-Shishu Suraksha Karyakram (JSSK).

Under the JSSK, all pregnant women delivering in public health institutions are entitled to free and cashless delivery, free C-section, exemption from user charges, free medicines, blood, consumables and diagnostics and free diet for three days in case of normal delivery and seven days in case of C-section.

The minister has also asked the states to prepare a policy articulation document, an essential drugs list and standard treatment protocols and introduce a procurement system and supply chain management.

“States already have a budget to purchase drugs but it isn’t enough. The latest allocation is to support the state budget for 2012-13,” said a ministry official.

Officials said that states will have to procure drugs through an open tender. Companies applying for the tenders will have to have good manufacturing practices compliance certificate, a no-conviction certificate and should have a specified annual turnover. The drugs will also have to carry a not-for-sale label printed on the packaging.

The ministry says upto 75% of private out-of-pocket (OOP) health expenditure is on purchasing drugs of which 76% is spent on purchasing OPD drugs.

The free medicines for all the programmes are estimated to cost Rs 28,560 crore during the 12th five year plan.

At present, the public sector provides healthcare to 22% of the country’s population and it is likely to swell to 52% by 2017 once medicines are provided for free from 1.6 lakh sub-centres, 23,000 primary health centres, 5,000 community health centres and 640 district hospitals.

Planning Commission says 39 million Indians are pushed to poverty because of ill health every year.

Around 30% in rural India didn’t go for any treatment for financial constraints in 2004. In urban areas, 20% of ailments were untreated for financial problems the same year. About 47% and 31% of hospital admissions in rural and urban India, respectively, were financed by loans and sale of assets.

A ministry official said it is being made mandatory for all doctors in the public sector to prescribe generic drugs and salt names and not brands.

The Cabinet has approved the setting up of a Central Procurement Agency (CPA) for bulk procurement of drugs.

“Only a handful states will be able to roll out free medicines by this year end,” a ministry official said.

Strongly backed by Prime Minister Dr Manmohan Singh himself, the free-medicines-for-all scheme has been referred to as the “real game-changer”.

The ministry has sent the National List of Essential Medicines, 2011, (348 drugs which includes anti-AIDS, analgesics, anti-ulcers, anti psychotic, sedatives, anesthetic agents, lipid lowering agents, steroids and anti platelet drugs) to all the states to use it as reference to prepare their EDL.

Tamil Nadu has been providing free medicines in its public health centres for the past 15 years, while Rajasthan introduced it last October. Both these states have a corporation that runs the show with complete functional autonomy.

A Planning Commission panel had said drug prices have shot up by 40% between 1996 and 2006. It said that during the same period the price of controlled drugs rose by 0.02%, while those in EDL increased by 15%. The price of drugs that were neither under price control, nor under EDL grew by 137%.

States have cut down on spending to purchase drugs, adding to aam aadmi’s woes.

A study by the Public Health Foundation of India recently found that while India’s per capita OOP expenditure for healthcare costs has gone up from Rs 41.83 in 2005 to Rs 68.63 in 2010, the per capita spending on drugs increased from 29.77% to 46.86% during the same period, while hospitalization cost went up from 11.20% to 22.47%.

Outpatient expenditure also increased from 30.63% to 46.16%.

Catastrophic spending, or percentage of households spending more than 10% of their overall income on healthcare, is nearly 15% in states that have insurance in place as against 11% in those that don’t have such policies.

Times View

Indians spend heavily out of their own pockets to purchase out-patient drugs, so providing free essential medicines is a welcome move from the government. However, it will remain a meaningless gesture unless good-quality drugs are provided, doctors are monitored to ensure that they prescribe generic drugs rather than branded ones and states put in place a transparent procurement system and supply chain management.

Anybody ill here and seen a doctor yet?


 

KRISHNA D. RAO,  The Hindu

 
GLOOMY PROGNOSIS: For the hardship that rural doctors have to endure, government service offers relatively little in terms of quality of life. Photo: Singam Venkataramana
The Hindu
GLOOMY PROGNOSIS: For the hardship that rural doctors have to endure, government service offers relatively little in terms of quality of life. Photo: Singam Venkataramana

Addressing the scarcity of medical practitioners in rural India is fundamental to achieving universal health care in the country

The Planning Commission’s draft 12th Plan for health has attracted much debate and controversy. Critics have been quick to direct their attention at two issues in it — the proposed increase in government health spending from one per cent to 1.58 per cent of GDP, and the “managed care model.” The spending increase was rightly felt to be grossly inadequate to move India towards achieving universal health care. The “managed care” model was expected to relegate the government’s role to a purchaser of services and undermine its role in the service provision. By focusing on these two issues, the debate on the 12th Plan for health, and indeed the Plan’s approach paper itself, ignores some of the more fundamental obstacles to achieving universal health care in India. For one, the scarcity of rural doctors currently prevents the delivery of even basic clinical services to needy citizens. Simply spending more or changing the way health services are purchased will not solve this problem.

Urban-rural divide

People deliver health services. Urban Indians can be forgiven for thinking that there are enough doctors in the country. Indeed, our cities are abundant with all manner of clinics, diagnostic centres and hospitals. But having a qualified doctor nearby is a rarity for the vast majority of Indians who inhabit the country’s rural spaces. According to the 2001 Census, there is a tenfold difference in the availability of qualified doctors between urban and rural areas i.e. one qualified doctor per 8,333 (885) people in rural (urban) areas of India. Addressing this rural scarcity is fundamental to efforts for achieving universal health care in India.

There are several notable reasons why doctors are reluctant to serve in rural areas. Fundamentally, the professional and personal expectation of medical graduates is not compatible with the life of a rural doctor. Their ambition lies in becoming medical specialists. Once they specialise, the professional, income, lifestyle, and family life opportunities in cities make rural jobs unattractive. Moreover, with private medical schools and their high fees dominating medical education, it makes little sense for medical graduates to take up jobs that don’t offer them the opportunity to recover their investment.

The scarcity of rural doctors places an important responsibility on the government. However, its efforts to place government doctors in rural posts have been largely unsuccessful. For the hardship that rural doctors have to endure, government service offers relatively little in terms of remuneration, quality schooling for their children and a chance at a decent family life. Human resources in the State health services are also poorly managed.

For instance, there is little transparency about transfers and postings because they are a source of both corruption and political patronage in the health system. Absenteeism is another issue. Indeed, most of the court cases facing State health departments have to do with human resource issues. However, given the professional and personal expectations of doctors, it appears unlikely that large increases in salaries and management changes will attract adequate numbers to government jobs and rural posts.

Situation abroad

Interestingly, many high, middle, and low-income countries also face a scarcity of rural doctors. Many of them have ameliorated this problem by using non-physician clinicians to deliver basic health services. In the United States, the United Kingdom, many countries in Africa, and even in South Asia, individuals such as nurse-practitioners or medical assistants, who have some years of basic clinical training, perform many of the clinical functions normally expected of fully qualified doctors. In sub-Saharan Africa and many parts of Asia, clinical services in rural areas are possible only because of these non-physician clinicians. They provide a range of clinical functions, including basic clinical services, manage deliveries, caesarean sections and abortions. Importantly, assessments from a variety of settings have shown that they perform as well as doctors.

Clinician cadre

India, however, has had an uneasy relationship with mid-level clinical cadres. At the time of India’s independence, licentiate medical practitioner (LMP)s, who underwent three years training, comprised nearly two-thirds of the qualified medical practitioners (the other one-third being doctors) and they mostly served in rural areas. LMPs were abolished after Independence but doctors never really occupied the space that LMPs vacated. Now, the shortage of rural doctors has forced some States to look towards non-physician clinicians for relief. Clinicians with around three years of clinical training currently serve at government rural health clinics in Chhattisgarh and Assam. Importantly, assessments of their performance in Chhattisgarh have shown them to be as competent as doctors for delivering basic clinical care. And because their training focuses on serving as rural clinicians and their career ambition is to have a government job, these clinicians, as the Chhattisgarh experience shows, have a greater likelihood of staying and serving in rural areas. The Central Health Ministry has proposed to expand this clinician cadre nationally through the Bachelors of Rural Health Care (BRHC) course. Unfortunately, expanding this cadre has met with considerable opposition and a former health minister even labelled them as “qualified quacks.”

The road to universal health care in India necessarily requires a serious assessment of basic problems that afflict the health system like the lack of human resources in rural areas. While this piece has focused on doctors, the rural scarcity of other health worker cadres such as nurses, lab technicians and pharmacists is equally acute and equally deserving of serious attention.

Higher government spending on health or how health services are purchased will do little to ensure that all Indians have health care if there are inadequate numbers of trained health workers with the right skill mix. The experience of other countries and two States in India show that non-physician clinicians, whether they are three-year trained clinicians or nurse-practitioners, can be part of the solution.

(Krishna D. Rao is senior health specialist, Public Health Foundation of India, and visiting faculty, Department of International Health, Johns Hopkins University, U.S. The views expressed are solely his and not of his affiliated institutions.)

 

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